1821164039 NPI number — RETINA SERVICES OF ILLINOIS, LLC

Table of content: (NPI 1821164039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821164039 NPI number — RETINA SERVICES OF ILLINOIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA SERVICES OF ILLINOIS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821164039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7447 W TALCOTT AVE STE 345
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60631-3714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-972-2700
Provider Business Mailing Address Fax Number:
847-972-2712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7447 W TALCOTT AVE STE 345
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-972-2700
Provider Business Practice Location Address Fax Number:
847-972-2712
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHROEDER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-972-2700

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  036-068461 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036095676 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF4390 . This is a "MEDICARE RETIRED RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036045862 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1637185 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 214702 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036068461 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 214701 . This is a "MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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